Insurance Information

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Assignment and Release (Insured Patients) I certify that I (or my dependent) have insurance coverage with

and I AUTHORIZE, REQUEST AND ASSIGN MY INSURANCE COMPANY TO PAY DIRECTLY TO THE PHYSICIAN/MEDICAL PRACTICE, INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the providers to release all information necessary, including the diagnosis and the records of any exam or treatment rendered to me, in order to secure the payment of benefits. I authorize the use of this signature on all insurance claims, including electronic submissions.

Signature (X) :

Date:

Type of Injury

MVC

Worker’s Comp

Slip and Fall

Other

Was the MVC on the job?

Yes

No

Time of Day of MVC:

You were:

Driver

Front Pass.

Rear Pass.

Motorcycle Dr.

Motorcycle Pass.

Other

Vehicle driven by:

Vehicle (Yr, Make, Model):

Your Est. Speed at crash:

Your Est. Speed at crash Options:

Stopped

Slowing

Accelerating

Other Vehicle (Yr, Make, Model):

Road Conditions:

Dry

Damp

Wet

Snow

Ice

Other:

Other Road Conditions:

Head Restraints:

None

Integral Type

Adjustable Type:

Up

Down

Unknown

If Adjustable, was the position altered by the crash?

Yes

No

Was the seat back adjustment altered by the crash?

Yes

No

Was the seat broken?

Yes

No

Shoulder /Lap belt:

Wearing

Not Wearing

Did air bag deploy?

Yes

No

If yes, were you struck?

Yes

No

Where?

Body Position:

Good

Forward Lean

Other:

If Other

Head Position:

Hands:

One on wheel

Two on Wheel

N/A

Brakes Applied?:

Yes

No

Crash Description:

Aware of Impending Collision?

Yes

No

During the crash:

Did you strike any parts of the vehicle?

Yes

No

Describe:

Wearing hat or glasses?

Yes

No

If yes still on after MVC?

Yes

No

Loss of Consciousness?

Yes

No

If Yes, how long?

Estimated property damage to your vehicle? $

Rate the other vehicle’s damage:

None

Minimal

Moderate

Major

Was there a police report made?

Yes

No

After the crash:

Symptoms:

Headache

Dizziness

Nausea

Confusion/Disoriented

Neck/ Back Pain

Paresthesia

where?

Extremity Pain?

Yes

No

Where?

When did symptoms first appear?

Immediately

Afterward

Where did you go after the crash?

Home

Work

Hospital

MD

By EMS?

Yes

No

Emergency Dept:

Radiographs:

Yes

No

Parts Imaged:

Results:

Medications:

Other Instructions:

File 1

File 2

File 3

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No matter the condition, we have the treatment for you. The expertise at Premier Medical Group ensure that you will never need to look elsewhere for your health needs. Our team includes medical doctors, nurse practitioners, doctors of chiropractic and acupuncturists. Our friendly and professional team will enable you to have a positive experience every time!